Limitations and Barriers to Implementing Pharmacoinvasive Strategy in STEMI in Developing Nations
System-Level Infrastructure Barriers
The absence of regional STEMI networks represents the single biggest barrier to implementing pharmacoinvasive strategies in low- and middle-income countries (LMICs), compounded by inadequate financial resources, personnel shortages, and virtually nonexistent emergency medical services systems. 1, 2
Critical Infrastructure Deficits
Emergency medical services are fundamentally lacking in resource-limited settings, preventing coordinated pre-hospital identification, ECG transmission capabilities, and early fibrinolytic administration that are essential for pharmacoinvasive pathways. 1, 2
Cardiac catheterization laboratories are far too few to serve large STEMI populations and are almost always clustered in urban locations, while the vast majority of patients live in rural areas with poor transportation infrastructure. 1
Inadequate staffing and bed capacity at tertiary hospitals often forces diversion of STEMI patients, leading to excessively long transfer times that undermine the time-sensitive nature of pharmacoinvasive therapy. 2
Transfer and Logistics Barriers
Routine inter-facility transfer protocols are severely impeded by the absence of ambulance-based ECG capabilities, policies forcing patients to the nearest hospital regardless of PCI capability, and financial disincentives that actively discourage referral to PCI-capable centers. 2
Specific Transfer Obstacles
Ambulance systems lack monitoring equipment and trained paramedics, making safe transfer of post-fibrinolysis patients to PCI centers within the critical 3-24 hour window extremely challenging. 1
Political and societal support for STEMI systems remains transient or challenging, as many LMICs continue to prioritize infectious disease programs despite the epidemiologic transition to chronic disease-predominant mortality. 1
Public policy reforms are urgently needed to improve timely access to primary PCI and address the economic implications of establishing hub-and-spoke STEMI networks. 2
Pharmacologic Evidence Gaps and Cost Barriers
Streptokinase—the most cost-effective fibrinolytic available in LMICs—has never been evaluated within a pharmacoinvasive strategy in any randomized controlled trial, whereas landmark trials like STREAM used tenecteplase, which is often cost-prohibitive for LMIC health systems. 1, 2
Drug-Specific Limitations
Fibrin-specific agents (tenecteplase, tissue plasminogen activator) can be cost-prohibitive compared with streptokinase in resource-constrained settings, yet the efficacy of streptokinase in a pharmacoinvasive approach remains untested. 1, 2
The optimal antiplatelet agent for pharmacoinvasive care remains uncertain; the TREAT trial demonstrated that ticagrelor did not reduce cardiovascular events compared with clopidogrel in patients receiving fibrinolysis. 1, 2
Ethnic variability in antiplatelet response poses additional challenges, as pharmacokinetic studies in East Asian populations have shown higher ticagrelor exposure and platelet inhibition with prospective trials reporting safety concerns. 2
Patient Presentation and Timing Challenges
Patients with STEMI in LMICs frequently present late with prolonged ischemic times, and it remains unknown whether the longer interval between fibrinolysis and subsequent PCI in these settings yields the same efficacy observed in STREAM and TRANSFER-AMI trials. 1, 2
Delayed Presentation Issues
The benefit of fibrinolysis diminishes significantly beyond 6 hours from symptom onset, yet late presentation is common in LMICs due to poor health literacy, delayed recognition of symptoms, and geographic barriers to care. 1
Accurate estimation of transfer time is critical for deciding between fibrinolysis versus immediate transfer, but unreliable estimates in LMIC settings frequently lead to inappropriate therapy selection. 2
Decision-Making and Coordination Complexity
The critical decision to administer fibrinolysis versus immediate transfer hinges on accurate transfer time estimates, yet sophisticated communication systems required for effective coordination between non-PCI-capable hospitals and PCI centers for planned angiography 3-24 hours after fibrinolysis are largely absent in LMICs. 2
Triage Algorithm Challenges
High-risk patients (anterior infarction, left bundle-branch block, Killip class >1) require immediate transfer even after successful fibrinolysis, adding complexity to triage algorithms that are difficult to implement without robust communication infrastructure. 2
Patients presenting within 2 hours of symptom onset who face excessive transfer delays pose particularly challenging decision points, as fibrinolysis may be superior to delayed primary PCI in this narrow window. 1
Volume-Outcome and Quality Measurement Gaps
A strong positive correlation exists between annual primary PCI procedure volume and survival outcomes, making low-volume centers in LMICs suboptimal for delivering the PCI component of pharmacoinvasive care. 2
Data and Quality Infrastructure Deficits
Comprehensive mapping of population access to thrombolytic or PCI centers within guideline-recommended time frames is largely absent, hampering evidence-based resource planning and network design. 1, 2
Established quality-indicator frameworks for auditing pharmacoinvasive strategy implementation in real-world practice are lacking, limiting systematic performance assessment and continuous quality improvement. 2
Financial and Social Barriers
Upfront out-of-pocket payments represent a formidable barrier for most patients accessing healthcare systems in LMICs, requiring creation of easily accessible, preferably cashless payment systems at any approved STEMI care facility to eliminate this obstacle. 1
Economic Obstacles
Social insurance schemes or universal health insurance coverage for populations below the poverty line is critical for implementation of STEMI programs and ensuring equitable access to emergency care. 1
Government participation and funding from health budgets is essential, including legislation to accredit STEMI hospitals, prescribe minimum training and infrastructure requirements, and enforce quality care standards. 1
Educational and Literacy Barriers
- Lower literacy and education levels among average persons in LMICs result in delayed symptom recognition, poor understanding of the urgency of seeking care, and reduced adherence to post-discharge medications and follow-up. 1
Common Pitfalls to Avoid
Never delay fibrinolysis waiting for transfer if primary PCI cannot be achieved within 120 minutes of first medical contact, as this eliminates the benefit of any reperfusion strategy. 1
Do not implement pharmacoinvasive protocols without establishing reliable transfer mechanisms for routine angiography at 3-24 hours, as fibrinolysis alone without subsequent PCI yields inferior outcomes. 1
Avoid selecting low-volume PCI centers as hub facilities in STEMI networks, as operator and institutional volume directly correlates with survival outcomes. 2